Are You a Vaccine Guidelines Ace? Test Yourself

Tue, Jan 24, 2017


vaccination CPT quiz

Vaccination coding crosses many specialties. See if you’ve got what it takes to code these common services. Answer the questions below based on the CPT® guidelines for vaccine immunization codes.

Take the Quiz

1. True or false: You may report vaccine immunization administration codes 90460, 90461, and 90471-90474 in addition to the vaccine and toxoid codes 90476-90749.

2. Which of the following codes is appropriate for IM vaccine administration not accompanied by face-to-face counseling by a physician (or other qualified health care professional) for a patient over 18 years of age?

  • A. 90460
  • B. 90461
  • C. 90471

3. Documentation shows a significant separately identifiable 99213 service performed at the same encounter as the vaccine administration. Do CPT® guidelines allow you to report the E/M service in addition to the vaccine admin?

  • A. Yes
  • B. No
  • C. The guidelines don’t specify

4. Code 90460 applies to the “first or only component of each vaccine or toxoid administered.” Which of the following is true?

  • A. A component refers to all antigens in a vaccine that prevent disease(s) caused by any number of organisms.
  • B. Multi-valent antigens against a single organism are considered a single component of vaccines.
  • C. Adjuvants contained in vaccines are considered to be component parts of the vaccine.

Check Your Answers

1. The correct answer is True. You may report both an admin code and a vaccine/toxoid code for vaccinations. Keep in mind that Medicare requires G codes for administration. For instance, for pneumococcal vaccine admin, you should report G0009 (Administration of pneumococcal vaccine).

2. The correct answer is C for 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]). The answer isn’t obvious from the descriptor for 90471, but the guidelines support this choice, and both 90460 and +90461 have descriptors that begin with “Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional …”

3. The correct answer is A. The CPT® guidelines indicate you may report office and other outpatient services (99201-99215), consults (99241-99245), emergency department services (99281-99285), and preventive medicine services (99381-99429) in addition to the vaccine admin code. Keep in mind that payers may not follow CPT® guidelines. For example, Medicare CCI edits bundle established patient office visit code 99211 (sometimes called a nurse visit code) into codes like 90471.

4. The correct answer is B. The other two are not true. Answer A would be true if it stated “caused by one organism” instead of saying “caused by any number of organisms.” Option C would be true if it stated adjuvants “are not considered to be component parts.”

How About You?

Do you code for vaccinations? How do you keep up with the changing codes and different payer rules?

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HCPCS 2017: Which Supplies & Services Made the Leap Away From C Codes?

Fri, Jan 20, 2017


HCPCS 2017 C code changes

In the world of HCPCS, C codes are a special bunch. CMS initially created C codes for use on Hospital Outpatient Prospective Payment System claims, but rule changes now allow a limited number of other providers to use the codes, too, such as Critical Access Hospitals and Indian Health Service hospitals.

Restrictions on reporting C codes matter because they aren’t intended for physician use. And that adds some complexity to coverage and reimbursement.

Below are 2016 C codes that moved to other sections in HCPCS 2017. Having a non-C code doesn’t automatically equate to coverage or reimbursement, but it’s worth checking whether your payer will cover the new codes relevant to you. The codes are listed under the range names provided by HCPCS 2017.

Chemotherapy Drugs

  • Daratumumab
    • 2016: C9476, Injection, daratumumab, 10 mg
    • 2017: J9145, Injection, daratumumab, 10 mg
  • Elotuzumab
    • 2016: C9477, Injection, elotuzumab, 1 mg
    • 2017: J9176, Injection, elotuzumab, 1 mg
  • Irinotecan liposome
    • 2016: C9474, Injection, irinotecan liposome, 1 mg
    • 2017: J9205, Injection, irinotecan liposome, 1 mg
  • Necitumumab
    • 2016: C9475, Injection, necitumumab, 1 mg
    • 2017: J9295, Injection, necitumumab, 1 mg
  • Talimogene laherparepvec
    • 2016: C9472, Injection, talimogene laherparepvec, 1 million plaque forming units (PFU)
    • 2017: J9325, Injection, talimogene laherparepvec, per 1 million plaque forming units
  • Trabectedin
    • 2016: C9480, Injection, trabectedin, 0.1 mg
    • 2017: J9352, Injection, trabectedin, 0.1 mg

Clotting Factors

  • Idelvion
    • 2016: C9139, Injection, factor IX, albumin fusion protein (recombinant), Idelvion, 1 I.U.
    • 2017: J7202, Injection, factor IX, albumin fusion protein, (recombinant), Idelvion, 1 I.U.
  • Nuwiq
    • 2016: C9138, Injection, factor VIII (antihemophilic factor, recombinant) (Nuwiq), 1 I.U.
    • 2017: J7209, Injection, factor VIII, (antihemophilic factor, recombinant), (Nuwiq), 1 I.U.
  • Pegylated factor VIII
    • 2016: C9137, Injection, factor VIII (antihemophilic factor, recombinant) pegylated, 1 I.U.
    • 2017: J7207, Injection, factor VIII, (antihemophilic factor, recombinant), pegylated, 1 I.U.

Diagnostic and Therapeutic Radiopharmaceuticals

  • Choline C-11
    • 2016: C9461, Choline C 11, diagnostic, per study dose
    • 2017: A9515, Choline C-11, diagnostic, per study dose up to 20 millicuries

Drugs Administered by Injection

  • Argatroban
    • 2016: C9121, Injection, argatroban, per 5 mg
    • 2017: J0883, Injection, argatroban, 1 mg (for non-ESRD use)
  • Aripiprazole lauroxil
    • 2016: C9470, Injection, aripiprazole lauroxil, 1 mg
    • 2017: J1942, Injection, aripiprazole lauroxil, 1 mg
  • Mepolizumab
    • 2016: C9473, Injection, mepolizumab, 1 mg
    • 2017: J2182, Injection, mepolizumab, 1 mg
  • Reslizumab
    • 2016: C9481, Injection, reslizumab, 1 mg
    • 2017: J2786, Injection, reslizumab, 1 mg
  • Sebelipase alfa
    • 2016: C9478, Injection, sebelipase alfa, 1 mg
    • 2017: J2840, Injection, sebelipase alfa, 1 mg

Miscellaneous Drugs

  • Ciprofloxacin otic suspension
    • 2016: C9479, Instillation, ciprofloxacin otic suspension, 6 mg
    • 2017: J7342, Installation, ciprofloxacin otic suspension, 6 mg
  • Hymovis
    • 2016: C9471, Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg
    • 2017: J7322, Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg

Procedures/Professional Services (And CPT®)

  • Dermal filler injection for LDS
    • 2016: C9800, Dermal injection procedure(s) for facial lipodystrophy syndrome (LDS) and provision of Radiesse or Sculptra dermal filler, including all items and supplies
    • 2017: G0429, Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy)
  • Laryngoscopy with injection
    • 2016: C9742, Laryngoscopy, flexible fiberoptic, with injection into vocal cord(s), therapeutic, including diagnostic laryngoscopy, if performed
    • 2017: 31573, Laryngoscopy, flexible; with therapeutic injection(s) (e.g., chemodenervation agent or corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral
    • 2017: 31574, Laryngoscopy, flexible; with injection(s) for augmentation (e.g., percutaneous, transoral), unilateral
  • Peri-prostatic material placement
    • 2016: C9743, Injection/implantation of bulking or spacer material (any type) with or without image guidance (not to be used if a more specific code applies)
    • 2017: 0438T, Transperineal placement of biodegradable material, peri-prostatic (via needle), single or multiple, includes image guidance

Skin Substitutes and Biologicals

  • PuraPly
    • 2016: C9349, PuraPly, and PuraPly antimicrobial, any type, per square centimeter
    • 2017: Q4172, PuraPly or PuraPly AM, per square centimeter

How About You?

Did you find any good news in the HCPCS 2017 updates?

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3 Things to Know Before Reporting Spine Code 63030

Tue, Jan 17, 2017


63030 lumbar laminotomy


That’s the national Medicare rate for lumbar laminotomy code 63030 in January 2017. To help ensure you collect every dollar you deserve (but not a penny more), keep these three tips in mind for proper reporting.

1. Know How to Count Interspaces

Watch for the word “interspace” at the end of the descriptor for 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar).

Spine coders have to be anatomy aces with a clear understanding of interspace vs. vertebral body to be sure they code correctly.

Example: L1, L2, and L3 add up to three vertebral bodies. But there are only two interspaces, L1-L2 and L2-L3.

You report 63030 per interspace, so be sure you’re counting interspaces and not vertebral bodies.

2. Pick +63035 for Additional Levels

If the surgeon performed the laminotomy procedure described by 63030 on more than one lumbar interspace at the same session, you should not report 63030 twice.

Instead, you should report 63030 for the first interspace and for each additional interspace, report +63035 (… each additional interspace, cervical or lumbar [List separately in addition to code for primary procedure]).

Code +63035 has a national Medicare rate of $201.34.  That’s significantly less than 63030, so using the correct code is important to ensure accurate reimbursement that doesn’t lead to payback demands from payers.

Example: If the surgeon performed the laminotomy service on two lumbar interspaces, on the right side. Your coding may look like this, depending on your payer’s modifier reporting preferences:

  • 63030-RT (Right side), 1 unit
  • +63035-RT, 1 unit.

3. Turn to Modifier 50 for Bilateral Service

Both CPT® and Medicare consider 63030 to be a unilateral code, meaning that 63030 represents a service on just one side of the body.

If the surgeon performs the laminotomy service on both sides of the same interspace, you should append modifier 50 (Bilateral service) to 63030 for additional payment. Code +63035 is also unilateral and accepts modifier 50.

Example: If the surgeon performed bilateral laminotomy services on two lumbar interspaces, your coding may look like this, depending on your payer’s modifier reporting preferences:

  • 63030-50, 1 unit
  • +63035-50, 1 unit.

If you’re aware of the CPT® instruction under both 63030 and +63035 to append modifier 50 for a bilateral service, you may think this tip is pretty obvious. But you shouldn’t assume Medicare applies CPT® rules. For instance, 69210 (Removal impacted cerumen requiring instrumentation, unilateral) specifically states unilateral in the descriptor, but Medicare will not pay extra if you append modifier 50.

You can confirm Medicare’s bilateral indicator for a code in the Medicare Physician Fee Schedule. Both 63030 and +63035 have bilateral indicator 1 at the time of this post. Medicare defines indicator 1 this way: “150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.”

How About You?

What do you think is the most challenging aspect of coding spine services?

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What You Need to Know About the 2017 OIG Work Plan

Fri, Jan 13, 2017


OIG 2017 Work Plan

The 2017 HHS OIG Work Plan is out, revealing what’s in the crosshairs for special scrutiny. There’s a good chance there’s something in its 101 pages that affects you. Make sure your team’s work is up to scratch on these topics listed in the Medicare Parts A and B/Other Providers & Suppliers section of the OIG Work Plan for 2017.

Note: This list offers just a few highlights of interest to individual providers and labs. Review the complete Work Plan to be sure you’ve got all your bases covered.


  • Clinical Diagnostic Laboratory Tests: Each year, the OIG has to analyze the top 25 lab tests by Medicare payment. The review is part of seeing how CMS is doing implementing a new market-based Medicare payment system that uses rates paid by private payers.
  • Histocompatibility Labs: Labs that provide testing for bone marrow and organ transplants need to be sure their cost information supports payment, specifically being related to beneficiary care, and being reasonable, necessary, and allowable based on Medicare rules.
  • Independent Clinical Lab Billing: The OIG sees independent clinical labs as being at risk of overpayments and wants to identify those labs that submit improper claims regularly.

Transitional and Chronic Care Management

  • Transitional Care Management (TCM): The OIG wants to be sure Medicare didn’t inappropriately pay for chronic care management (CCM), end-stage renal disease (ESRD) services, and prolonged services without direct patient contact during the same service period as TCM.
  • CCM: We just saw that the OIG is checking for TCM and CCM paid during the same period. They’re also checking to make sure you didn’t get paid for CCM during the same period as home health care supervision or hospice care and certain ESRD services.

Financial Interests Reported Under Open Payments Program

  • Sunshine Act: Physician financial relationships with manufacturers and group purchasing organizations are under the microscope. To read more about the Sunshine Act, click the link for a CMS Fact Sheet.

Referring or Ordering Physician Compliance

  • Ordering Eligibility: If you aren’t eligible to order or refer for services and supplies, then Medicare shouldn’t be paying for those services and supplies. The OIG will be checking up on both physicians and nonphysician practitioners.


  • Modifier: If you use the modifier indicating personal performance of anesthesia, you’d better be sure you can back it up. The OIG is checking to make sure the services weren’t just medically directed instead.

Home Visits

  • House Call: Here’s a fun fact. From 2013-2015, Medicare paid $718 million for physician home visits. The OIG wants to be sure those visits were reasonable and necessary.

Prolonged Services

  • Extra E/M Time: Prolonged services should be pretty rare, according to the OIG Work Plan. To avoid taking a hit for this audit target, make sure your coding complies with the Medicare Claims Processing Manual, Chapter 12, Section

Chiropractic Services

  • Noncovered Services: Medicare has some pretty strict limits when it comes to covering chiropractic services, and maintenance therapy doesn’t make the cut. The OIG wants to be sure Medicare has been paying for services appropriately.
  • Trends: Chiropractic services have a history of inappropriate payments. The OIG is pulling together results of its prior work to check for patterns so the OIG can provide recommendations to Medicare on how to reduce vulnerabilities.

Physical Therapists

  • Outpatient: Finding proper documentation to support work performed by independent physical therapists was tough during a previous review, according to the OIG. This round, the OIG is checking for high utilization rates for outpatient services.

Portable X-Ray Equipment

  • Suppliers: Improper payments to portable X-ray suppliers for multiple trips to a facility in a single day are on the OIG’s radar. Technologist qualifications are getting scrutinized, too.

Sleep Disorder Clinics

  • Wrong repeat: Sleep testing procedures 95810-95811 had high utilization in a 2010 review. Now the OIG is checking up on repeated tests on the same patient.

Rx Drugs Section Bonus: Drug Waste

  • Modifier JW: In the Prescription Drugs section of the OIG Work Plan, you’ll see the OIG wants to be sure you’re using common sense (and not greed) when choosing the size of a single-use vial. They’ll be checking claims for modifier JW to see how much drug waste you’re getting paid for.

How About You?

Do you have any OIG audit experiences to share?

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What Do the AMA and ACP Say About ACA Repeal?

Tue, Jan 10, 2017


Affordable Care Act

The president-elect ran on a platform of repealing the Affordable Care Act (ACA). What will actually happen is still up in the air. The American Medical Association (AMA) and American College of Physicians (ACP) have both recently posted letters to congressional leadership about healthcare system reform. Below is a summary of each letter.

From the AMA

The AMA released a letter on Jan. 3, 2017, with the points detailed below:

  • The AMA supported the ACA as an improvement.
  • The AMA continues to support making “high quality, affordable health care coverage accessible to all Americans.”
  • The AMA recognizes the ACA has issues that need to be addressed and is willing to work with lawmakers to improve the health care system and ensure Americans have access to coverage.
  • The AMA states that before policymakers take any actions that could alter coverage, they should provide details on replacement options so people can decide whether they prefer the new option to the current policy.

From the ACP

The ACP is a community of internists. The ACP letter, dated Jan. 3, 2017, covers many of the same points at the AMA letter, but makes more of a point of expressing “strong concern” that Americans are at risk of losing the coverage and protections established by the ACA:

  • The ACP supports universal health coverage.
  • The ACP supports the ACA because it reduced the uninsured rate, provides protections for patients with pre-existing conditions, prohibits insurers from establishing certain limits, and ensures coverage of preventive services.
  • The ACP cites independent, nonpartisan analysis that indicates millions will lose coverage if Congress proceeds with the plan to repeal and replace the ACA, particularly with no alternative being currently available for evaluation.
  • The ACP offers to participate in discussions of how to improve the ACA, specifically in these areas:
    • Bring more healthy patients into the insurance markets to stabilize those markets for everyone’s benefit
    • Increase consumer choice in insurance and providers
    • Ensure adequate networks
    • Support new improvements at the state level, including Medicaid, while ensuring current protections aren’t lost, the red tape doesn’t get worse, and the focus on primary care continues.

What About You?

What changes would you like to see when it comes to health care system reform?

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Have You Checked the HCPCS Corrections File? Lab Coders, I’m Looking at You

Fri, Jan 6, 2017


HCPCS corrections 2017

If you code for drug testing, retinal prostheses, or seat lift mechanisms, the HCPCS 2017 corrections document has some items of interest aimed directly at you.

Where Is the HCPCS Corrections File?

The CMS website includes an Alpha-Numeric HCPCS page. You can download the current code set as well as a couple of the past code sets from this page.

For 2017, one of the file options is for 2017 Corrections to the Alpha-Numeric HCPCS File.

What Is in the HCPCS Corrections File?

At the time of this posting, the corrections file includes this information, effective Jan. 1, 2017 (check the 2017 corrections file linked above for complete details):

  • Add C1842 (Retinal prosthesis, includes all internal and external components; add-on to C1841). The HCPCS Coverage Code listed is D, which indicates special coverage instructions apply.
  • Remove cross reference codes Q0078-Q0080 (deleted long ago) from current seat lift mechanism codes E0627-E0629.
  • Terminate presumptive drug test codes G0477-G0479. Remember that CPT® 2017 added new drug testing codes with descriptors almost identical to G0477-G0479.
  • Revise the long descriptors for definitive drug test codes G0480-G0483 (see next section).
  • Add G0659 (Drug test[s], definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers [but not necessarily stereoisomers], including but not limited to GC/MS [any type, single or tandem] and LC/MS [any type, single or tandem], excluding immunoassays [e.g., IA, EIA, ELISA, EMIT, FPIA] and enzymatic methods [e.g., alcohol dehydrogenase], performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard[s] for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes). The coverage code is C, meaning carrier judgment. The pricing indicator 21 tells you the price is subject to the national limitation amount.

What Changes in the G0480-G0483Descriptors?

In the descriptor for new code G0659, you see the wording “performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s).”

Keep that in mind when you review the main change to the descriptors for G0480-G0483, which references the use of universally recognized internal standards and quality control.

Because the descriptors all start out the same, you can get an idea of all the changes by looking at how the old and new descriptors for G0480 compare. Bold in the descriptors shows where the wording and formatting differs between the original HCPCS 2017 file and the corrections file.

G0480 descriptors:

  • Original file: Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed
  • Corrections file: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed.

How About You?

Do you use the codes in the corrections file? What do you think about the changes?

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8 Great Ways to Keep Your 2017 Coding On Target

Tue, Jan 3, 2017


multiple scope rule

Hello, 2017! The year we’ve been talking about for so long is finally here. Try these eight helpful hints to keep your claims clean and on track from the start.

1. Post Major CPT® Updates Front and Center

Long-time coders may remember the days when Medicare offered a 90-day grace period to adjust to new codes. But these days, if you’ve got a Jan. 1 date of service, then you need to be using the code set effective for the new year.

To help remember changes to the codes you know by heart, use whatever means work best for you, like putting a sticky note on your monitor that you can’t miss.

With changes to common codes for mammography and spinal injections — not to mention the moderate sedation coding revolution — plan ahead to keep your brain from going on cruise control when you code.

2. Check Those HCPCS Units

If you’ve got new HCPCS codes to report, then make sure you double check your units before you finalize your claim. Getting the number of units wrong is costly, but it’s fairly common because you have to remember to calculate the units based on the amount listed in the code descriptor.

For example, for new code J9145 (Injection, daratumumab, 10 mg), 1 unit of J9145 covers up to 10 mg of daratumumab administered.

Important: Don’t forget that Medicare has a new national rule requiring use of modifier JW to report wasted drugs on a separate line. Take the time to confirm you’ve reported all units appropriately, in line with the new rule.

3. Pay a Visit to LCD Policies

When new codes come into play, your payers update their policies. It may take a while for policies to catch up to the updates, but it’s a smart move to check the coverage rules for your common procedures. In particular, note how CPT® 2017, HCPCS 2017, and ICD-10-CM 2017 changes affected the covered code combinations.

4. Keep Tabs on Denials

Checking for policy changes goes hand in hand with watching your denials. For example, if any of your codes changed in a way that affects the number of services covered by a single unit of the code, you will definitely want to watch for denials to be sure your payer has updated coverage policies in line with the changes. Checking denials also can help catch any patterns in errors in case you missed an update.

5. Check Errata for Important Corrections

The AMA posts corrections to CPT® throughout the year as needed. Checking the errata and corrections document regularly is especially important if you use a paper manual that won’t receive updates the way an online coder will.

6. Scan MPFS Indicators

The Medicare Physician Fee Schedule (MPFS) database provides a lot of information beyond RVUs. Before you submit a claim, scan through the MPFS indicators to be sure things like global days and bilateral indicators have stayed the same for the new year.

7. Prevent CCI-Related Denials

We got nearly 100, 000 new Correct Coding Initiative (CCI) edits on Jan. 1, 2017, adding to the already impressively long list. Trying to remember on your own whether two codes are bundled is a guaranteed road to denial. Check your claims for CCI edit issues to stop denials before they happen.

8. Focus on Today, Plan for Tomorrow

The January updates are big, but they’re not alone. Updates to CCI, MPFS, HCPCS, and more will be here in just a few months on April 1, followed by the July and October 2017 updates. We’ll be getting our first glimpse of 2018 updates before we know it.

Mark your calendars now for when you want to start preparing for each new round of updates, whether that means catching up on your Coding Alerts or ensuring your team will have the data they need when the updates go into effect.

How About You?

Share your tips for staying up to date on the changes that affect coding.

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Quick Q&A to Take Multiple Scope Know-How Up a Notch

Fri, Dec 30, 2016


multiple scope rule

Happy New Year! We’ve made it to the last SuperCoder blog post for 2016, and what a year it’s been. Sometimes after a whirlwind of chaos, it’s good to get back to the fundamentals. With that in mind, today we’re looking at some simple tips for the next time you’re dealing with the multiple scope rule, a crucial concept if you want to understand the Medicare Physician Fee Schedule (MPFS).

1. Where Can I See Some Sample Calculations?

The basic idea behind the multiple scope rule is that if the surgeon performs multiple endoscopic procedures on a patient at the same session, then you’ll receive full reimbursement for the highest valued procedure and reduced reimbursement for the others.

For subsequent related endoscopies, you get paid based on the difference between the base code (defined in question 2) and subsequent code.

If the subsequent endoscopy is in a different family, expect that subsequent scope to get paid at a discounted rate under multiple surgery rules.

For two sets of unrelated procedures, things get really interesting. You apply the special endoscopy rules to each series, then apply multiple surgery rules.

Helpful: For sample calculations, click the link to see a Multiple Endoscopic Procedures document from Palmetto.

And feel free to share that info with any math teachers you know who have students claiming they’ll never use math when they’re adults.

2. Where Can I Find the Base Code for an Endoscopic Procedure?

Within the code ranges for endoscopic procedures are code families, meaning those that have descriptors that share a common beginning but then differ after the semicolon. Typically you can find the base procedure code by looking for the first code in a family of codes.

Example: Code 43191 is the base code for 43192-43196. All of their descriptors begin with “Esophagoscopy, rigid, transoral,” but then a semicolon and additional text follows that initial wording, distinguishing each code from the rest. For instance, look at how 43191 and 43192 differ in descriptor wording only after the semicolon:

  • 43191, Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen(s) by brushing or washing when performed (separate procedure)
  • 43192, Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance.

To confirm that you have the correct base code, you can check the ENDOBASE (Endoscopic Base Codes) column of the MPFS database. Your online coding resource may provide the information, or you can go to Medicare’s Physician Fee Schedule Search tool.

For instance, if you check the ENDOBASE (Endoscopic Base Codes) entry for 43192, you’ll see 43191 listed.

Knowing the base code helps in calculating reimbursement, as question 1 mentioned, but it’s also important to know that the base endoscopy won’t be reimbursed separately when reported with another code from the same family.

3. Where Can I Find the Multiple Procedure Indicator?

The MPFS includes a MULT SURG (aka Multiple Procedure or Modifier 51) column. In the Multiple Procedure column, you want to look for two indicators in particular, 2 and 3, to see how the multiple scope rule will affect your reimbursement. Here are the definitions from the Medicare Claims Processing Manual (page 95 of the linked PDF):

  • 2 = Standard payment adjustment rules for multiple procedures apply. If the procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 50 percent, 50 percent, 50 percent, and by report). Base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.
  • 3 = Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified in the endoscopic base code field. Apply the multiple endoscopy rules to a family before ranking the family with the other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure). If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure. Payment for the base procedure is included in the payment for the other endoscopy.

You may see indicator 2 with a base procedure code and indicator 3 with other codes in the code family.

Final tip: Although you may see the MULT SURG column referred to as the modifier 51 column, Medicare and some other payers ask that you not use modifier 51 (Multiple procedures). The payer will take care of that for you.

How About You?

What questions do you have about the multiple scope rule?


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Get Ready for 99,490 New CCI Edits Coming January 1

Tue, Dec 27, 2016

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CCI update January 2017

January 1 means new CPT® and HCPCS codes, and one consequence of that is a whole lot of changes to National Correct Coding Initiative edits (aka NCCI edits or CCI edits). While every quarter brings updates to CCI edits, the changes to the January version tend to be pretty numerous because they have to incorporate new edits for the new codes and delete edits for whatever codes were deleted for the year.

Helpful: CMS now provides a spreadsheet each quarter that shows just the changes, with one tab for additions, one tab for deletions, and one tab for modifier indicator changes. While working from the spreadsheet (instead of the official version or a trusted CCI Edits Checker) isn’t recommended, reviewing the changes-only file is a great way to spot patterns in the edits. Here are a few patterns you’ll see in the CCI edits going into effect on Jan. 1, 2017.

Focus on Spinal Injections and Moderate Sedation for Additions

The spreadsheet shows 99, 490 CCI edit additions for Jan. 1, so we won’t be going through them all here! But you can definitely pick up trends about what’s getting bundled, and chances are you won’t be too surprised. Over and over again, you’ll see these codes in the Column 2 position:

  • 62320-62327, interlaminar epidural or subarachnoid injections
  • 99151-99153, moderate sedation by different provider that the one doing the surgery
    • Tip: Codes 99151-99153 are mostly bundled into other anesthesia codes (0xxxx), rather than into procedure codes
  • 99155-99157, moderate sedation by same provider who’s doing surgery.

There are plenty of other additions, too, such as the usual bundling of integumentary system codes into new surgical procedure codes and bundling of radiology codes into new codes that specifically include imaging guidance, so be sure to check the edits for the codes related to your specialty.

Deletions: As you may have guessed, the 55,760 deletions have a pattern, too. The deletions remove edits for 62310-62319 (which 62320-62327 replace) and 99143-99150 (which 99151-99157 replace).

Always Check the Modifier Indicator Changes

The tab showing modifier indicator changes is an important one because it shows existing edits that have new reporting rules. You’ll see which edits have been changed from modifier indicator 0 (meaning you may never override the edit) to modifier indicator 1 (which means you may override the edit when documentation supports doing so), and vice versa.

Here’s an overview of the modifier indicator changes listed in the spreadsheet for Jan. 1, 2017. This list is intended as a summary only, so check the individual edits before making any coding decisions.

Change from 0 to 1 (may override):

  • Edits bundling paravertebral block codes 64461 and 64463 into trigger point injection codes 20552 and 20553
  • Edits bundling A95xx radiopharmaceutical codes into certain 783xx and 788xx nuclear medicine codes
  • Edits bundling 95941 and G0453 (intraoperative neurophysiology monitoring from outside the OR) into 95940 (intraoperative neurophysiology monitoring from inside the OR)

Change from 1 to 0 (may NOT override):

  • The laryngoscopy edit bundling biopsy code 31576 into lesion removal code 31578
  • Edits involving 6158x and 6159x codes for skull base surgical procedures

How About You?

Are any of these CCI edits a surprise, or do they create CCI bundles you don’t agree with?

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